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Tuesday, October 30, 2012

This past weekend I attended my first IMP Camp. IMP originally stood for Ideal Micro Practice, but now stands for Ideal Medical Practice.

I went because after years of being an ardent supporter of team-based primary care, I decided last spring to switch to practicing geriatrics in a solo micropractice.

This is a career development which I still consider with mild surprise. I was after all (and continue to be) a huge fan of Tom Bodenheimer's work proposing that primary care should be delivered by high-functioning teams, rather than by overwhelmed clinicians trying to do everything themselves.

However, finding a high-functioning team to join is not so easy. Part of the problem is the still-predominating fee-for-service payment system, which generally doesn't reimburse medical work that isn't provided face-to-face and by a "billable provider" (i.e. physicians, NPs, PAs, but not RNs). This can really cripple outpatient geriatric care, which I believe ideally would involve plenty of phone follow-up, care coordination, and nurse-led coaching interventions.

Of course we now have a move towards accountable care organizations (ACOs) and value-based payments, but it's not yet clear how this trend will mean for the experience of the average on-the-ground primary care clinician. (Will ACOs be yet another stakeholder complaining about what we didn't do? Or will they lead to substantive support in helping us do our work well?)

Furthermore, even when funding mechanisms support a team-approach to primary care, one still needs the team to be high-functioning. As most people who've worked on teams can tell you, not all teams work well. This is especially true in primary care, where healthcare providers may be asked to take on very different roles without getting adequate coaching and support in making the requested changes. (To his credit, Bodenheimer is well aware of the rhetoric-reality gap when it comes to teamwork.)

What's a clinician to do when she wants to provide high quality outpatient care but is worn out by primary care as usual?

My answer -- for now -- is to try an independent micropractice. The micropractice is the brainchild of Dr. Gordon Moore, a family medicine doc who realized that by leveraging technology to strip his practice setting down to a minimum of staff (as in, none) and overhead, he could practice better primary care. Better, as in, his patients were happier and he was happier. In particular, Moore found that this model:

Improved access, leading to better care and better patient satisfaction. Being the only one answering the phone means a clinician can respond quickly to patient requests, and is always in the loop.

Allowed more attention to direct patient care. A small lean practice requires less management and coordination, especially when technology is effectively leveraged to handle administrative work.

Facilitated longer patient visits. The average primary care practice spends 50% of revenue to cover overhead. Less overhead means less need to pack in revenue-generating visits every day, which means a clinician can earn a decent salary while giving patients longer visits (often resulting in higher patient satisfaction, provider satisfaction, and better care).

This last point, however, is what makes many primary care wonks nervous. Longer visits may mean happier patients, but if a clinician can make a living caring for a smaller patient panel, many start to worry about exacerbating the looming shortage of primary care providers.

In fact, in listening to Gordon present this past weekend on the key tenets of Ideal Medical Practices (he has very sensibly broadened the IMP term and focuses on what constitutes ideal outpatient medical care, rather than on micropractices per se), I was struck by how well the IMP concepts dovetail with what I hear patient/consumer advocates saying they want.

What I see patients/consumers clamoring for, and how the IMP model meets the need:

Access: they want to be able to reach their healthcare provider promptly, as needed.

IMPs offer excellent phone access and usually open access scheduling.

Relationship: they want to feel that the healthcare provider knows and understands them, and they want to be able to work with a compatible provider repeatedly.

IMPs prioritize the patient-physician relationship; in small IMPs almost all patient needs are met by the patient's usual provider.

Patient/consumer centered care: they want the healthcare to be organized around their priorities, and not just what the provider, or healthcare system, thinks should be the priorities.

IMPs emphasize care that is driven by the patient's needs, goals and values. Many use the "How's Your Health?" online questionnaire to regularly provide clinician's with the patient's self-assessment of health and needs.

Technology: they want healthcare providers to communicate via email and other new technologies, and to keep up with emerging technologies that might improve health and care coordination.

Virtually all IMPs use technology to maintain a high-efficiency/low-overhead practice. Most IMP providers are available to patients through some form of messaging.

Coordination: they want their primary healthcare provider to communicate, connect, and coordinate with other providers.

Technology often facilitates this.

Support in self-management: they want providers to help them feel empowered and confident in their ability to self-manage their health.

By leveraging a collaborative relationship, a focus on patient-centered care, and technology, IMPs are generally able to successfully address this need.

In short, IMPS generally offer a smaller intimate practice setting which is well-suited to providing the close and collaborative patient-physician relationship that historically has been the foundation of good primary care. Just as many of us enjoy patronizing smaller local businesses, especially if we get to know the owners, patients often enjoy a smaller independently owned practice.

What about team-based patient-centered medical homes? Well, those are a good concept too, but transforming practices may take some time. (You can read about lessons learned from the National Demonstration Project here.)

In the meantime, yours truly is trying out the micropractice/IMP model for herself, and will keep you posted on how it goes. Fortunately for me, the IMP community is largely focused on providing practical assistance to other clinicians trying to start or maintain IMP practices, so I've been getting some much appreciated support and advice. ((Disclosure: the IMPs have formed a nonprofit group, and I paid to become a member last April, which gives me access to some members-only informational resources.) I'd certainly heartily endorse this creative and spunky group to other clinicians contemplating a similar practice shift. Thanks IMPs!

Me with Dr. Anna Maria Izquierdo-Porrera, a geriatrician with an amazing practice in Maryland (www.care4yourhealth.org)

Dr. L. Gordon Moore, who is now doing really fascinating work for Treo Solutions (negotiating improved payment models with big payors). Who wouldn't listen to a man in tie-dye?

Thursday, October 25, 2012

Here is an issue that I would love
to get some technological assistance with: medication reconciliation.

Has anyone discovered a good tool
for medication reconciliation, that works for the outpatient setting?

As an outpatient geriatrician, I
spend a lot of time reviewing medications, and it's not uncommon for my
patients to be taking 10-15 medications. This is clinically VERY important; medications are a top cause of delirium, falls, and other adverse effects in non-hospitalized elders.

The problem: even if I have an
accurate list of what has been prescribed by myself and the other involved
doctors (a big if -- more on that soon), matching this up with what the patient is
taking tends to take a while. Here's what I used to do at my previous clinic
job, which had a medication list in the e-prescribing system, and also in the
paper chart:

Get the patient to bring in all bottles. (Usually involves multiple reminders and some coaxing; it's hard to get patients to not juts bring in their outdated list from 6 months ago.)

As I look at a bottle, check it off against the
existing list. (Oh wait, if I want an existing list I can scribble on, I
need to copy the list we have, or print from e-prescribing; doing either task will set me further behind.)

Forget about checking it off. I decide to just write
down all the meds, and then compare it against the list I have, using my
eyeballs and brain to stop the discrepancies.

Hm. These two lists are long, and the meds are in
different orders. Maybe I should start by counting the two lists and
seeing if I have the same number of meds on each one.

Aha! The original list says metoprolol 50mg bid, but
the patient has brought in a bottle that says metoprolol 100mg bid.
Discrepancy identified!

As I start to inquire about this discrepancy, the
patient brings up three other problems of greater concern to her, and I
never finish spotting the other discrepancies during the visit.

Yes I admit it, I often found it
very difficult to get through comprehensive medication reconciliation at an
outpatient visit.

But this is part because this is one
of the many tasks that providers are often left to do with eyeballs and brain,
even though of course computerized technology can do this faster and better.

Here's a hypothetical technological set-up to do medication reconciliation faster:

Patient's med list is kept in some kind of program,
perhaps web-based. Ideally this should be accessible for viewing by the
patient as well as the provider.

Meds at the visit get input into the program. Ideal
would be for the entry to bypass human eyes and finger, like barcode
scanning. Heck, maybe you could even snap pictures of QR codes on the bottle, as these are now all
the rage. (Why don't prescription med bottles come with barcodes that can be read in clinic??)

The computer doesn't care that the meds were entered in
a different order. It can rearrange them and identify the discrepancies in
a snap.

One second later, provider has a list of the
discrepancies, and can start investigating.

So, does this exist?? My preliminary
Google search reveals that:

Microsoft HealthVault
can download medication info from some big pharmacy chains like CVS and
Walgreen's. I suppose you'd have to enter your own meds post
hospitalization. And it's unclear from their promotional materials how
HealthVault helps patients, families, and providers spot discrepancies.

A company called PatientKeeper
claims to have recently rolled out the "First Physician-Friendly Med
Rec Software Application". Unclear how you enter meds at a visit, or how usable
it is in outpatient setting.

In general, when I look into technology for medication reconciliation, I overwhelmingly find tools like this one, which are:

designed for med rec in hospital, not outpatient setting

focus on reconciling what has been prescribed, rather than what the patient actually has on hand.

Obviously it's very important to achieve medication reconciliation during hospital admission and discharge.

But as everyone agrees that it's important to provide good outpatient care, in order to avert hospitalizations and maintain wellness, we really need better med rec tools for the practicing primary care clinician.How are the rest of you managing outpatient medication reconciliation for elders? Have you come across any tool or technology that can make this med rec process more doable in the usual outpatient clinic setting?

Tuesday, October 23, 2012

Last week Wired Magazine hosted a Wired Health Conference (subtitled "Living by the Numbers") in NYC. As there was lots of buzz about Dr. Eric Topol's talk, "Information into Action," I watched it online after the fact. It's a very interesting interview with Wired's Thomas Goetz, in which Topol describes a handful of new technological tools that he feels doctors should be using. In fact, he states that "we're trying to get a lot of things out into the real world of everyday care."

Now, I'm a practicing doc interested in finding and adopting technology that will improve geriatric care. So whenever I hear about a new tech tool recommended to doctors, two questions come to my mind:

Does this sound like it will improve the clinical care of my patients (frail and vulnerable elders), at a reasonable cost?

What would it take for a doc such as myself to integrate using this tool into my workflow?

In this post I'll briefly describe the tech tools Topol mentioned in his talk, and share my initial thoughts on them.

The tech ideas described by Topol and Goetz during this talk (my thoughts on each idea are in purple):

Pharmacogenomics-based prescribing. How exactly might you personalize medical care based on someone's genome? Topol proposes pharmacogenomics as a good place to start. The FDA has a list of drugs with known genomic interactions (I found it here; 117 drugs on it). For instance, according to the talk, Plavix (clopidogrel) doesn't work in 1 of 3 people due to a genomic factor that can be identified through www.23andme.com.

Wow, between stents and strokes, many older adults have an indication for Plavix. I'd heard that some are resistant, but if a commonly used drug really doesn't work for a third of people, then considering pharmacogenetics would improve clinical care for my patients. Cost-effectiveness as of yet unclear to me.

But how am I supposed to know which drugs require special dosing? Hard to keep track unless a specific genomic testing recommendation is going to start popping up in the e-prescribing systems. (Vague warnings that there is a genomic interaction without further specifics on what to do are not very helpful to providers.)

Added twist: Uptodate.com, the clinical decision-support tool I use on the fly, has a topic page on clopidogrel resistance, but the summary recs "suggest against routine testing of patients for "clopidogrel resistance", whether by in vitro testing of platelet function or by genetic testing for CYP2C19 poor metabolizers (Grade 2C)."

Uh-oh. Discrepancy between what I hear from Wired Health and Uptodate. I could dig through the literature to arbitrate, but in general, I am just going to go with the clinical decision support tool I trust.

Point-of-care genotyping. Topol explains that a barrier to using genomic information is the usual week-long delay in getting test results. He proposes that one is more likely to act on genomic information if one can get it at the point of care (POC), rather than having to wait a week. He's been working with a company called DNA Electronics, which is developing a rapid POC genotyping test. They are envisioning pharmacists doing the test (customer gets to shop in the store for 15 min while awaiting results), and then being able to help match up "the right person with the right drug and right dose."

Hm. Unclear whether the test would have to be ordered by a doc, would get ordered by insurance, or would be up to the patient to request. There are pluses and minuses to all three options; suspect the issue will be heavily wrangled in next few years.

The value of increased access to genomic testing would really depend on what was being genomically tested for, and whether acting on that information has been shown to improve outcomes. (As you can see from the example above, there is clearly debate on when genomic testing adds value.)

Workflow question: when test results are available after 10-20 min, does the pharmacist call a doc, or dispense based on a protocol? How are the docs notified?

Nanosensors in the bloodstream. This one's a little further off in the future, but this source of Big Data's coming within a few years to a bloodstream near you. Scripps Digital Medicine has a grant from Qualcomm Foundation to work on these nanosensors (90 microns), that would be carried by the bloodstream and embed in a capillary somewhere. The sensors could track a bloodborne signature of pathology, like signs of an impending heart attack or autoimmune attack, and send the information to a nearby smartphone.

There is also the question of what kind of continuous data monitoring is appropriate for the geriatric population; what I think would help me provide better care is the ability to query a data stream related to symptoms and behavior.

AliveCor. This is the iPhone-into-ECG technology mentioned above. Topol uses it all the time, despite it not yet being FDA-approved. (Doctors, you can get one here if you pretend to be a veterinarian.)

I do have a clinical need for something like this. I see a lot of homebound older folks who otherwise do not have easy access to an ECG. And I often hear irregular heart sounds, and wonder if they are having ectopy versus afib.

But assuming the FDA eventually approves something like this, who will help me interpret the rhythm strip? There was a time during my UCSF residency when I got really good at reading ECGs. (I once pissed off a bigwig attending by questioning the ECG machine's automated interpretation, which the attending had accepted. The cardiology fellow sided with me, but I was still left in deep diplomatic doo-doo.) Eight years later, I'm hardly ever called upon to interpret a rhythm strip on the fly, and I don't feel comfortable doing much more than identifying afib. I would certainly feel better using this if it came with a feature allowing me to send to someone who could confirm the interpretation, or some other form of clinical decision support. I don't need more work or uncertainty to deal with.

Wearable continuous glucose monitor. This one uses a 27 gauge needle and you can continuously follow your blood glucose on your smartphone. Unclear to me how it's different from what some diabetics currently wear (other than talking to the smartphone). Topol sounded like he's envisioning regular people wearing these and continuously getting feedback on how their diets are affecting blood glucose.

This probably has some value for the exploding population of diabetics and prediabetics. For my own older patients however, I can only envision recommending this to the truly brittle diabetics, or others in which continuous monitoring is shown to improve outcomes.

This is yet another source of Big Data, so we again need to consider what patients will expect of physicians, and how we can equip physicians to deal with this data stream.

Vscan. "Why would I listen to lub-dub?" asks Topol, when a handy pocket ultrasound can just show you just what the heart valves are up to. Topol believes that this should be "part of the physical exam." He points out that this could save a lot of money by replacing some of the thousands of $800 echocardiograms that are done every year. Note to medical educators: Topol says that Mt. Sinai's med school is now giving Vscans to the entering students, rather than stethoscopes (um... and the lung sounds?).

This is basically offering patients a POC abbreviated echo. For frail elders who are already struggling with too many appointments and getting to clinics, this could be beneficial, and probably cost-effective (unless all the POC echos generate follow-up complete echos).

But how often will I find something using Vscan that changes management without requiring a full echo?

And how do I get to the point of using a Vscan? How much training would I need to feel comfortable making a preliminary interpretation of what I see? Who is available for a backup read? How do I document the findings in my EHR?

Who's going to pay for me to have this Vscan anyway? I'm in private practice, as are many primary care docs. Am I supposed to pay to get this because this will bring more patients into my office? (Um, a geriatrician always has more than enough demand for her services, and there's a shortage of primary care docs in general.)

My conclusions on Topol's talk:

He's got a lot of interesting ideas on how we doctors might be using technology soon. He is certainly promoting these ideas to consumers before we know if these technologies will improve health outcomes. I can't blame him for this; the usual methods of conducting peer-reviewed research can't possibly keep up with the pace of technological innovation. A little consumer pressure might be what we docs need to up our game and move into the 21st century.

Still, before society invests a lot of money into healthcare driven by these technologies, the outcomes issue is important. Technological advances are one of the primary drivers of increasing health care costs, and historically have not always generated cost savings, although that's not to say the right technologies couldn't do a better job of this in the future. Needless to say, it's not the job of tech companies or most tech evangelists, including Wired, to ensure that adopting new technologies bends the cost curve. They provide the tools and spread the word. Policymakers and payors have to figure out what to do with them.

Plus there are special considerations related to geriatrics and the care of medically complex adults. Geriatrics in particular is riddled with examples of excess technology and diagnostic efforts leading to harmful excess care, and unimproved outcomes. So I find it hard to not feel cautious when thinking about implementing these technologies in the Medicare population, whose fate is about to make or break the nation's financial outlook.

Last but not least, there are the nitty-gritty issues related "getting this into the real world of everyday care," which means getting everyday docs to use these new technologies:

How do we keep up with an exploding array of new diagnostic and therapeutic techniques? It's not just about rebooting medical school; how will we reboot the million doctors already at work? We need viable strategies that allow us to keep up with the changes (assuming the experts agree on what new technologies we should be using). The week of paid CME time that many get is not enough.

How do we get time and infrastructure to help patients with the data that they will apparently be bringing to us?

How does society plan to make it viable from a financial and workflow perspective, for us to adopt this neat new diagnostic equipment in our day-to-day practice?

So, it's all good food for thought, but at the end of the post, is this geriatrician willing to adopt any of the technologies listed above?

Actually, I thought about ordering the Alivecor last night. I have a homebound and confused elderly patient who could use an ECG, but I haven't yet found a mobile ECG service to give me some info on what his heart is up to. He is anxious and desperately wants to avoid going to the ER, so pursuing an ECG under current conditions would impose a significant burden on him and his family.

I'll keep thinking about it for now. I do have a cardiologist friend who would read the strip, if I'm able to securely email it to her.

Thursday, October 18, 2012

As I described earlier this week, in my line of doctoring I frequently find myself struggling to obtain the kind of big data that I need: data on a frail elder's symptoms and behaviors over the past days to weeks.

So I was delighted to meet yesterday with Julie Menack of 21st Century Care Solutions, a Bay Area geriatric care manager (GCM) with a special interest in applying technology to the care management of the elderly. She pointed me towards eCaring.com, an online platform for managing and monitoring home care services. (Disclosure: Julie is a paid consultant for eCaring. I have no current or planned financial ties to either eCaring or to Julie, although given that Julie and I provide complementary services to frail elders in the Bay Area, we will probably have an opportunity to serve the same client/patient eventually.)

The idea of eCaring seems to be this: caregivers, especially the ones hired by care managers, often keep daily logs to record the care provided, as well as how the care repicient is doing. Of course historically records have been kept on paper, often in a "care binder."

The trouble with paper and binders, however, is that this information is difficult to share and analyze. I personally hate it when people refer me to a binder for information. It's the 21st century, people. If the information counts, it needs to be in a computer, AND backed up.

Enter eCaring. This company provides a computer-based platform for caregivers to record all this information (this part is called CareTracker). The information can then be shared with family, case managers, or healthcare providers, through review of the CareJournal, or by using the CarePortrait feature, which creates customized reports.

The platform will also eventually include an alert feature. Once the parameters of an alert have been defined, then entering a trigger prompts a notification sent by text or email to designated recipients.

Of most interest to me is that if information is regularly and properly
documented, this creates a database of information that is potentially
very useful to me clinically. The platform does support a form of
querying the data, to focus on a trend related to eating or pain, for
instance.

So will eCaring actually work for my purposes? And will it lead to better health outcomes for elders?

I can't say for sure, as I haven't tried it yet. And since it's fairly new, Julie herself is just starting to pilot it with clients.

However, the concept has a lot of potential. Finding an effective way to document and manage this information could be extremely helpful for care coordination purposes. And access to this type of information could help doctors such as myself evaluate common complaints that come up for geriatric patients.

In the end, the proof will be in the pudding. Entering a lot of data is often harder for on-the-ground users than we expect. For a doctor like me, the data also needs to be easily viewed, sorted, and queried; if it's a pain to do this, we'll find doctors yet again avoiding the information rather than engaging with it.

Another issue that will affect adoption is cost. eCaring is currently offering a free three month trial, but unclear to me how much it costs afterwards. And who will pay? Families out-of-pocket? Or perhaps hospitals post admission? Will accountable care organizations be interested?

Last but not least, as I've said before, if this becomes a stream of data aimed at providers, we will have to find ways to give providers time and infrastructure for reviewing and responding to the data. (We already have over 50% of docs in front-line specialties such as general internal medicine with signs of burnout; more data to take care of won't help unless working conditions become more supportive.)

Despite all these caveats, I'm excited to learn about eCaring, and hope to get an opportunity to try it out soon.

By the way, my brief Google search didn't turn up any similar products, but if you know of one, definitely let me know in the comments or by email.

Tuesday, October 16, 2012

Since deciding to delve into the world of healthcare technology and innovation, I've repeatedly come across the term "Big Data," which many claim will be transforming healthcare. As best I can tell, in healthcare terms, Big Data seems to refer to two overlapping ideas. One is that healthcare systems are currently collecting reams of health data, and by analyzing this data, we can identify patterns and signals that we can take action on. The other is that individuals can turn into personal repositories of big data, by frequently measuring various biometric and other parameters (i.e. personal tracking, which leads to the "quantified self"), and then this data can be analyzed and acted upon by the person and healthcare providers.

All well and good, but as with many exciting healthcare tech ideas, I find myself wondering:

"How is this going to help me get the data that I've been struggling to get?"

After all, my work requires me to obtain and process a lot of data, namely data regarding a person's behavior, symptoms, and abilities, and how all of these have changed over time.Will the Big Data movement help doctors like me?

Here's a little story to illustrate my data needs in practical terms. Not too long ago, I went on a housecall to see a very elderly man with mild dementia, who lives in a small residential board and care (B&C) facility. The staff there had called the patient's durable power of attorney (DPOA), saying that the patient, who we'll call Mr. A., had recently become agitated at night. A urine test had been negative for infection. The B&C staff was wondering if a sedative or other prescription might be indicated. The DPOA had visited the patient and did think he looked less energetic than usual.

"Doctor, what do you think is going on, and what should we do?"

(Actually, people usually just ask the second part of the question, but good medical practice dictates that a clinician should first form a theory of what might be going on, before deciding what to do.)

As many dementia caregivers can tell you, this is a common scenario, and doctors are commonly asked to weigh in and make things better.

The catch is that, to sort out this common situation, one needs data on what has happened. In particular, I needed to know:

When exactly did this problem start? Did it start suddenly, or did it come on progressively?

Was there an inciting event that can be identified?

Is Mr. A distressed at night every night, or just now and then? If now and then, can we identify other factors that fit with the pattern (bowel movements, use of certain medication, etc)?

How is his current strength and energy level different from his baseline?

I went to visit the gentleman in question, whom I had never met before. He was very charming and pleasant, but also hard of hearing, and with poor short-term memory. His physical examination did not reveal any obvious cause for the recent concerns. Unsurprisingly, Mr. A. was not able to provide me with the historical data that I needed to make sense of the situation.

So I interviewed the patient's primary caregiver at the B&C. But here too, the data was hard to obtain. The staffer is Filipino, and although his English seemed ok, he seemed to have difficulty understanding my questions on how Mr. A. seems different now compared to a few weeks ago. He was also inconsistent in his reports of how often specifying how often Mr. A has been having nighttime confusion.

Finally, the caregiver went to find his log book. This facility does not log every resident's behavior on a daily basis, just "as needed." We found two entries noting nighttime confusion, the last being a week prior. I left, still uncertain as to just how Mr. A. had changed compared to a month ago. I had just spent over 30 minutes trying to ferret out the data I need for my medical decision-making, and still was not sure I had accurate information to work with.

Given the shortage of geriatricians such as myself, it would obviously be very helpful if technology innovations resulted in my quickly being able access accurate data on a patient's behaviors and symptoms.

So, will the Big Data movement help a doctor like me? I would say this depends on two key factors:

Will emerging technologies facilitate the collection of data relevant to geriatricians? Let's face it, I don't currently feel a burning need for a "small, wearable sensor that can capture and transmit blood chemistry data continuously." What I need is something that reliably logs behaviors and symptoms, as well as medication use. [Update 10/17/12: Since yesterday Sano Intelligence, whose site my link points to, has removed the basic info on their blood chemistry sensor. But I am including a screenshot of the cached site below.]

Will Big Data shower doctors with information before we are equipped to triage and act on it? It sounds terrific to send more data to doctors, but we're currently already suffering from information overload. (I wrote about the trouble with apps sending data to doctors last week.) We first need to develop systems that allow us to act effectively on the information we already have.

The truth is, although I think Big Data offers a lot of potential for population health management, I'm a little worried about how it might play out regarding the care of individual geriatric patients. Each elderly person could certainly generate a significant stream of physiologic, behavioral, and symptomatic data. But often collecting more data from frail elderly patients results in more healthcare, much of which ends up being of uncertain benefit. (Example: more scans usually turns into more things to work up and investigate.)

However, here's an approach that sounds more manageable to me: a system that would allow doctors such as myself to specify the data to be collected, and that would make this data collection manageable and accurate for patient and caregiver.

In other words, instead of bombarding me with data and telling me to help the patient, what if the patient, the system, and I all first agreed on what information would be useful to gather, and then I received it?

Could I get a nightly confusion monitor for Mr. A please, along with an accurate log of his pain and constipation complaints, a record of medications taken including as-needed medications and over-the-counter drugs, and a daily measure of his physical energy, so I can study his trends and patterns? Please?

10/17/12: Here's a screenshot of Sano Intelligence's homepage as it was on 10/10/12, with a little description of the kind of data they could be providing:

Friday, October 12, 2012

Here's an exchange that frequently comes up between me and an overwhelmed family caregiver (CG):

Me: "You are doing such a fantastic job helping your mother out. She's really lucky to have you be so involved. And, it sounds like she needs more help at home than you're able to comfortably provide on your own. Have you considered hiring an in-home caregiver to come help out?"

CG: "How do I find someone reliable? How much does it cost?"

Me: "Umm....Let's see if we can connect you with a social worker who can help you. You can also try calling the Family Caregiver Alliance. They should have resources on how to hire in-home help, and they may have some kind of registry of home care providers."

Three weeks later:

Me: "Did you look into getting some help at home?"

CG: "Umm...I'm planning to, but I've been so busy..."

Six weeks later:

Me: "Did you look into getting some help at home?"

CG: "Umm...I have this list of agencies..."

And so it goes, with me continuing to encourage the beleaguered caregiver to get some help, and the caregiver struggling to address yet another complex task as he or she scrambles to keep up with the challenges of caregiving.

The problem, of course, is that as the doctor, I'm pointing at
something to be done, but am not able to lay out concrete simple steps that a family caregiver can execute. Instead of relieving the caregiver's stress, I'm giving him or her another complex problem to solve.

Family caregivers could certainly use some technology that simplifies the process of investigating and hiring in-home help.

The good news: some healthcare tech entrepreneurs are working on just this problem. As some may recall, last week when I briefly reviewed AARP's top healthcare innovations for 50+, the startup I was most interested in was Carelinx, an online platform to help people find and manage paid caregivers.

Well, Carelinx was featured at the Aging 2.0 event I attended last night, and after learning more about the concept, I still think this is a service that could meet an important need for families I work with.

(Full disclosure: Carelinx contacted me last week after I mentioned them on GeriTech.org and I recently lunched with CEO Sherwin Sheik, who was interested in my experience as a geriatrician. We have no current or planned financial ties. He did strike me as very nice and has personally experienced the challenge of trying to hire in-home help for a sister with MS and an uncle with ALS.)

Why? Because Carelinx reminds me of Airbnb, a service that I have found genuinely super helpful and an example of how Internet platforms can

1) make a complicated search task much easier, and

2) facilitate an individual-to-individual transaction.

Like Airbnb, Carelinx provides a user-friendly platform that facilitates searching for what one needs. Users can easily look through a roster of individuals proposing caregiving services, and filter based on criteria such as gender, years of experience, credentials, and types of past caregiving experience. If you choose to hire someone, the platform manages the scheduling, payments, taxes, and also insurance and bonding. (Confession: I'm not really sure what the bonding means, but sounds reassuring.)

An additional feature I found appealing is that the platform supports video interviews with a prospective caregiver, which is a great tool for getting a sense of a person before moving towards an in-person meeting.

Last but not least, Carelinx claims that since they charge less as a middleman than traditional in-home care agencies do, families can obtain help for less, and the caregivers themselves get paid more. If this is true, this is a great benefit for families, who often face financial constraints, and for the caregivers themselves.

Does Carelinx actually work well for families? I can't say, as I don't know anyone who has hired a caregiver through the service.

Obviously families looking for an in-home caregiver should consider other options. For some, working with an established agency that provides coordinated geriatric care management services may be a better fit. There may also be other companies online that do a better job allowing families to find a suitable caregiver. (However, my brief Google search today didn't turn up anything more promising: lots of agencies, lots of referral services, and Care.com, which does have a roster of available caregivers but doesn't seem to provide the infrastructure for managing an ongoing client-caregiver arrangement.)

And it's unclear to me how well an Internet company like Carelinx can screen and vet caregivers, although as Jim Sabin notes on the Over 65 Blog, that's been an issue with traditional agencies as well.

Still, when I consider the options I have historically provided (I do love you Family Caregiver Alliance, but I worry that my families need something that feels easier than this process), I think Carelinx's approach has terrific potential.

In many arenas, Internet platforms have replaced traditional middlemen (i.e.buying airline tickets, renting vacation homes, hiring freelancers). This has generally led to more transparency, better prices for consumers, improved customer service due to reviews and ratings, and an overall simplified experience.

Will this approach yield similar benefits in the realm of hiring an in-home caregiver? My guess is probably, but we'll have to see.

In the meantime, I'm glad to hear of another option that I can propose to families.

PS: Health services providers: if you know someone who's used Carelinx or a similar platform, I'd love to hear from you.

"Should I get an iPad for my own doctoring?" I found myself wondering a few months ago, as I was planning my new housecalls micropractice.

I got one. I sent it back. Here's the main reason why:

Typing is an integral part of the work I do with patients, and when participating in healthcare teams.

And I found that typing on the iPad was a lousy experience, even with Bluetooth keyboard and ZaggFolio.

Does doctoring really require that much typing? I suppose it depends on how you do your doctoring.

Here are the kinds of things I type while practicing my profession:

I type extensive written instructions for patients and caregivers, often as I'm talking with them about a plan.

I type search terms into Uptodate because I use clinical decision support in real-time.

I type notes when I'm on the phone with patients, to document what they say, and what I tell them.

I type notes when I collaborate with colleagues on patient care, because this helps me remember what they are telling me.

I type emails and secure messages, to communicate with patients, caregivers, and colleagues.

I type notes when I'm in administrative meetings, because this helps me pay attention.

I type things I need to do into my task-manager, to keep me on track and make sure I don't forget something important.

Last but not least: I do some typing when interviewing patients in person, but sometimes opt to jot a few notes on paper, with later input into my EHR.

Although I didn't take the test iPad out to see any patients, just using it at home felt like a serious drag on my documentation-intensive style. Encased in the Zaggfolio, the iPad weighed 2.7 pounds, which was only a little less than my Thinkpad x61. (Disclosure: I have bailed on Apple products before, having switched back to PC after using an iMac for three years, and having ditched the iPhone after using it for a year.)

So I sent it back. Now you may be thinking: How will you show patients pictures, or videos, or engage in FaceTime, or otherwise participate in 21st century doctoring?

Um...my Windows apps will do the trick, no? And my laptop, like most, comes with an integrated webcam. As for Internet connectivity while on housecalls or on the road, I use a Verizon 4G jetpack, which works very well.

Now I'll admit, I'd feel more modern and hip cruising around with an iPad. Especially here in San Francisco, I must seem positively fusty with my trusty black Thinkpad.

But what can I say. I haven't yet opted to use point-and-click templates while doctoring. To paraphrase Abigail Zuger, I like to write what I think, a privilege that may be widely underestimated.

My conclusion regarding iPads and doctoring: iPads are pretty good ways to consume information, but may be limiting to a doctor's ability to input information.

All those residents training with iPads: will they be writing what they think? Will they be writing personalized instructions for patients? Will they be writing to me, to coordinate care?

Wednesday, October 10, 2012

The Science section in the NYT has a special section on the "Digital Doctor" this week. The lead article, "Redefining Medicine with Apps and iPads," showcases UCSF resident Alvin Rajkomar, who is -- gasp -- using MedCalc on his iPhone, to help him manage hospitalized patients.

This Exhibit A of new digital doctoring made me laugh out loud. You see, when I was a third-year medical student over a decade ago, I and many other med students and residents were using a similar program. We had hot new devices called PDA (personal digital assistants), and had replaced the usual pocket references with digital equivalents. As a matter of fact, I recall using something called MedCalc and it came in handy throughout residency, although once the rubber hit the road in internship, I switched back to pocket books for some references. (You can't quickly skim lots of text onscreen the way you can skim pages of small text, and to this day, the one reference I always carry in my pocket when doctoring is my Tarascon Pocket Pharmacopoeia.)

A better glimpse into the future of smartphone-leveraged healthcare is in "Apps That Can Alert the Doctor When Trouble Looms," which highlights an area that truly is new, exciting, and also slightly scary in the expanding world of digital doctoring.

To summarize, companies are developing apps that monitor patient behavior, and then send the data to health providers. The apps described use GPS monitoring and accelerometers to track patient motion. The idea is that a significant change in motion pattern could be signaling an important change in health status. Presumably at this point some kind of signal would be fired off to a doctor.

Here's how they say it might be used for patients who have chronic illness and involved caregivers (i.e. my patients):

"Dr. Matthew Gymer, the director of innovation at Novant, said he wanted
to see how well the technology performed in alerting caregivers to
potential behavior changes in thousands of patients with different
conditions, including diabetes, chronic pain and heart disease."

Ok, let's talk about this. For now, we'll set aside issues of patient privacy (some call this Big Brother but I expect most patients won't mind) and properly calibrating the devices so that their alerts have good positive predictive value.

My main concern: are providers are ready and willing to be receiving this data?

Interestingly enough, some of the comments echo this line of concern, with one commenter (Atlanta mortgage broker) noting:

"These days, you can go repeatedly to your primary care and specialists
BEGGING for help, stating any dangerous mental state imaginable and
dangerous health issues such as uncontrolled diabetes and hypertension -
and they don't even call you back or give you a decent appointment
date..."

On the provider side, AKS says:

"You want to know the first thing i thought about as a doctor? Picturing
me getting sued by a patient or their family and the lawyer saying: this
app shows that you received this information, yet there is no record
that you acted on it. i'm literally supposed to act on it, pull the chart, and then note what the
app said and what i did, and why i did it, and why i didnt do something
else. tort reform before i use this app."

I think both commenters are highlighting the likely trouble with apps that send data to docs:

Is there infrastructure to facilitate medical intervention, i.e. at the minimum available appointment to be seen?

Doctors are already complaining of information overload and not having enough time to address patients' needs, especially in the outpatient setting. Front-line providers are experiencing 60% burnout. Is this going to make their professional lives better or worse?

Last but not least, I have to say that caregivers I've worked with often have little difficulty noticing that something is wrong with their loved one. It's after they notice that the problems start:

They don't know what to do or who to call, or even that they should call sooner rather than later (hence my search for delirium educational materials);

They are unable to promptly access by phone a provider who has decent information about the patient;

No appointments are available in the near future.

I do heartily agree with one researcher's point that relying on patient interviews to collect data is incredibly inefficient, so I'm interested in the promise of apps for this purpose.

But if the apps come before providers are ready and willing to get the data, we may very well see the current exodus from primary care get worse.

Tuesday, October 9, 2012

This
week is Health Innovation Week, and thousands of health tech people
have descended on San Francisco to participate in the Health 2.0 conference, a “showcase of cutting-edge innovation that's transforming
health and health care.” Many would say that if you want to see what healthcare could look like soon, Health 2.0 is the place to be.

So what might we expect in terms of impending changes to the care of geriatric patients? Today I'll share some thoughts on the yesterday's kickoff keynote speech, given by the healthcare futurist Joe Flower. (I watched the keynote via webstream on LearnItLive.)

Unsurprisingly, Joe described our current time as one of great instability, and predicted major changes coming up in healthcare, no matter what happens to the Affordable Care Act. Key drivers of change he cited included an aging population, the need to manage healthcare costs, increasing burdens of chronic disease (with a special shout-out to the obesity epidemic), and exciting technological innovations which he thinks will allow us to deliver better care for cheaper.

Based on these factors, Joe described the following shifts in healthcare. (It was unclear to me whether he is merely recommending these, or thinks they are quite likely to develop based on the big change drivers described). My comments and reactions are in purple.

Explode the business model. This, if I understood him correctly, requires changing reimbursements and financial incentives that usually shape healthcare delivery. This would allow a shift from physical geography of care to virtual geography of care. He also envisions the end of cost-shifting: instead of following the average cost of hip replacement, we'll be focusing on the cost of care for each individual patient, and trying to get it down.

Couldn't agree more re changing financial incentives. Geriatric patients in particular are disadvantaged by the current model which emphasizes volume of (short) face-to-face visits, and discourages care coordination. But many healthcare policy experts have been bemoaning the reimbursement system for years, and it's still there, currently interfering with attempts to create good primary care medical homes. Does Joe know about a viable plan to get this changed on a meaningful scale soon?

Keeping costs down for every individual patient? Patients are interested in this when they are using HSAs, it's dicier with frail elders using Medicare. Interesting recent NYT op-ed titled "How to Die" notes the downsides of emphasizing cost in certain situations.

Build on smart primary care. Prevention and primary care are apparently hot among the healthcare innovation crowd. Joe wants to see primary care get "smarter," which I think means an emphasis on addressing problems further "upstream." As an example, he cited the Vermont Blueprint for Health Chronic Care Initiative.

Definitely a laudable goal and I am all for better and smarter primary care, especially for frail and vulnerable elders who stand to gain a lot. How you make it happen for lots of elders is another story, especially given the shortage of healthcare providers with geriatric expertise.

The smart geriatric primary care models that jump to my mind are PACE (Program of All-Inclusive Care for the Elderly), followed by Guided Care and GRACE, but all of these are currently hampered by reimbursement issues, among others.

Put a crew on it. A reference to Atul Gawande's proposal that medicine needs to be based on pitcrews rather than lone cowboys. It also dovetails nicely with the current interest and emphasis on interdisciplinary teams to provide care. That being said, Joe's examples seemed to be of building an "integrated practice unit" for a specific medical problem.

How would these integrated practice units work for geriatric patients, who will have multiple chronic diseases and symptoms simultaneously? I worry that health tech innovation is going to focus on creating expert teams for specific diseases; will they mobilize to develop expert teams in caring for a frail older persons?

To me, this sounds like an expansion of current disease management services. So far, I've found such services to be problematic, since they require yet more coordination and usually don't provide good geriatric-specific disease advice. (Please don't bug my elderly patient about checking blood sugar three times a day without talking to me first!)

Last but not least: it takes a lot of work to create and maintain a well-functioning team. This needs more than lip-service; administrators need to give teams guidance and time for their teamwork; my personal experience is that this is often neglected.

Swarm the customer. This seems to mean two things. One, you extensively monitor the well-being of patients. Two, the moment something seems to be going wrong, you swarm in and fix it. As Joe pointed out, a small portion of the patients create a large part of the costs, so the goal is to spot those patients with extra need early. Per Joe, the people with the most needs offer the possibility of the greatest savings.

Intriguing to think about re geriatrics. Obviously we are constantly faced with situations in which early intervention leads to better health outcomes (which I feel better emphasizing, rather than less cost even though better outcomes often do cost less).

But geriatric patients also have high needs. My guess is that if you start monitoring them extensively, you will bring a lot of previously less seen issues out of the woodwork, and that will cost money. Some of those should be addressed because they are likely to lead to better outcomes. Other things will be like elevated PSAs: they will attract attention and evaluation, of unclear overall benefit.

This sounds like a good arena in which to involve geriatricians, who have expertise prioritizing health issues for this population, if you want to extensively monitor and pre-emptively intervene with frail elderly patients.

Rebuild all processes. "Measure, improve, try, and measure again." He emphasized getting close to the customer experience while doing this.

As a graduate of the VA Quality Scholars program, I love the idea of PDSA, CQI, and using measurement to guide process improvement. Lots of processes related to geriatric care need this.

As a former clinic director, I can tell you that this is damn hard work. It can and should be done, but resources will have to be allocated to support it, or you run the risk of souring your front-line providers on the idea.

In closing, Joe said the changes are going to force us to develop a leaner, smaller, and smarter system. I'm certainly all for change, but will it happen as soon as he thinks, and how will it play out for those of us caring for frail elderly patients?